A clone of elusive parents: gonadotroph adenoma-female type

A 69-year-old woman presented with visual disturbance. Perimetry testing revealed a bitemporal hemianopia. Brain MRI demonstrated a 2.2-cm gadolinium-enhancing pituitary mass. Previously she had been treated for hypothyroidism, hypertension, and dyslipidemia. She had hyperprolactinemia. Endoscopic transsphenoidal debulking improved her visual field defects. Histology showed a chromophobic adenoma. Electron microscopy showed elongated, polar cells with long, slender processes. The small uniform secretory granules were peripherally disposed, collecting heavily within cell processes. Based on electron microscopical characteristics the tumor is consistent with an ACTH-negative female gonadotroph adenoma. The parent cell of this rare variant of a pituitary adenoma is yet unknown.

Nicotine treatment of mild cognitive impairment: a 6-month double-blind pilot clinical trial

OBJECTIVE

To preliminarily assess the safety and efficacy of transdermal nicotine therapy on cognitive performance and clinical status in subjects with mild cognitive impairment (MCI).

METHODS

Nonsmoking subjects with amnestic MCI were randomized to transdermal nicotine (15 mg per day or placebo) for 6 months. Primary outcome variables were attentional improvement assessed with Connors Continuous Performance Test (CPT), clinical improvement as measured by clinical global impression, and safety measures. Secondary measures included computerized cognitive testing and patient and observer ratings.

RESULTS

Of 74 subjects enrolled, 39 were randomized to nicotine and 35 to placebo. 67 subjects completed (34 nicotine, 33 placebo). The primary cognitive outcome measure (CPT) showed a significant nicotine-induced improvement. There was no statistically significant effect on clinician-rated global improvement. The secondary outcome measures showed significant nicotine-associated improvements in attention, memory, and psychomotor speed, and improvements were seen in patient/informant ratings of cognitive impairment. Safety and tolerability for transdermal nicotine were excellent.

CONCLUSION

This study demonstrated that transdermal nicotine can be safely administered to nonsmoking subjects with MCI over 6 months with improvement in primary and secondary cognitive measures of attention, memory, and mental processing, but not in ratings of clinician-rated global impression. We conclude that this initial study provides evidence for nicotine-induced cognitive improvement in subjects with MCI; however, whether these effects are clinically important will require larger studies.

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that 6 months of transdermal nicotine (15 mg/day) improves cognitive test performance, but not clinical global impression of change, in nonsmoking subjects with amnestic MCI.

Venous thoracic outlet compression and the Paget-Schroetter syndrome: a review and recommendations for management

Paget Schroetter syndrome, or effort thrombosis of the axillosubclavian venous system, is distinct from other forms of upper limb deep vein thrombosis. It occurs in younger patients and often is secondary to competitive sport, music, or strenuous occupation. If untreated, there is a higher incidence of disabling venous hypertension than was previously appreciated. Anticoagulation alone or in combination with thrombolysis leads to a high rate of rethrombosis. We have established a multidisciplinary protocol over 15 years, based on careful patient selection and a combination of lysis, decompressive surgery, and postoperative percutaneous venoplasty. During the past 10 years, a total of 232 decompression procedures have been performed. This article reviews the literature and presents the Exeter Protocol along with practical recommendations for management.

Nutritional decline in cystic fibrosis related diabetes: the effect of intensive nutritional intervention

BACKGROUND

Reports indicate that nutritional and respiratory decline occur up to four years prior to diagnosis of cystic fibrosis related diabetes (CFRD). Our aim was to establish whether intensive nutritional intervention prevents pre-diabetic nutritional decline in an adult population with CFRD.

METHODS

48 adult patients with CFRD were matched to 48 controls with CF, for age, gender and lung pathogen status. Nutritional and other clinical indices were recorded at annual intervals from six years before until two years after diagnosis. Data were also analysed to examine the impact of early and late acquisition of CFRD.

RESULTS

No important differences in weight, height, body mass index (BMI), lung function or intravenous treatment were found between groups in the six years prior to diagnosis, nor any significant deviation over time. In those who developed diabetes, use of overnight enteral tube feeding (ETF) was four times as likely at the time of diagnosis, compared to controls [ETF 43.8% (CFRD) v 18.8% (CF Controls), OR 4.0, CI 1.3 to 16.4, p=0.01]. Age at onset of CFRD played a significant role in determining the pre-diabetic clinical course. Younger diabetics with continued growth at study onset (n=17) had a lower BMI from 2 years prior to diagnosis compared to controls [BMI 18.9 kg/m(2) (CFRD) v 20.8 kg/m(2) (CF Controls), diff=1.9, CI -0.1 to 3.7 p=0.04]. The BMI of older diabetics (completed growth at study onset) was equal to that of controls throughout.

CONCLUSION

Pre-diabetic nutritional decline is not inevitable in adults with CFRD, but is influenced by age of onset. In the group overall, those with CFRD are more likely to require ETF from 2 years prior to diagnosis. Despite intensive nutritional intervention, patients who continue to grow throughout the pre-diabetic years, show a level of nutritional decline absent in older adults.

Can Thromboelastography performed on kaolin-activated citrated samples from critically ill patients provide stable and consistent parameters?

Thromboelastography (TEG) is a potentially useful tool but analysis within 4-6 min of collection imposes limitations on its use and access. The use of citrate blood tubes potentially increases the time frame for processing specimens. There is, however, limited research on the stability of citrate specimens, timing of processing and the accuracy of TEG results. The purpose of this study was to examine the effects of early and delayed processing on TEG parameters using kaolin-activated citrated blood samples in the intensive care population. TEG analysis was performed on 61 patients. Blood was collected into two 3.2% sodium citrate (0.105 m) tubes. Kaolin-activated samples were analysed at 15, 30 and 120 min postcollection. TEG parameters analysed included reaction time (R), clot formation time (K), alpha angle (alpha), maximum amplitude, LY30, the coagulation index, time to maximum rate of thrombus generation, maximum rate of thrombus generation and total thrombus generation. Sixty-one critically ill patients were included. The results of the anova showed that time from collection was significantly associated with the TEG((R)) results (P < 0.05). On comparison of individual outcome variables, this difference in most cases was due to changes over time from 30 to 120 min. Furthermore, progressive changes in TEG parameters such as decreasing R were suggestive of a trend toward hypercoagulability of the specimens. Processing of kaolin-activated citrate TEG specimens can begin as early as 15 min postvenipuncture. However, delaying processing by more than 30 min leads to a significant change in results.